1. Two days of progressive abdominal pain in teenage girl Paul Lewis, MD James Cameron, MD January 2012

2. CC: “I shouldn’t of had that hamburger. I told you eating makes me sick.” HPI: 15-year-old girl presents to the emergency room with 2 day h/o RLQ pain. Pain onset progressive starting in epigastric region, focused to RLQ over last 10 hours. N/V x 3. Decreased oral intake. Had this before but not as bad. PMHx: Unremarkable. Rx: None. Soc: Does well in school. Is a top-ranked CxC runner. No EtOH, sex or drugs. Menarche at 13 years.. Clinical History 2

3. Gen: skinny but athletically built, appears appropriate for age Abd: + McBurney’s, +epigastric pain MSK: normal GU: +adnexal TTP Labs CBC: WBC 28.52 Neutrophils 92%. U/A: Some G+ and RBC, Neg nitrites, Neg ketone Pregnancy test: negative Focused Physical Exam 3

4. Appendicitis Early ectopic pregnancy, PID Urinary Tract Infection Stress fracture Clinical differential diagnoses 4 Diagnostic Plan – Ultrasound vs. CT scan – Clean catch U/A Treatment Plan – NPO, IV Fluids

5. Ultrasound versus CT scan 5 American College of Radiology (ACR) ACR Appropriateness Criteria www.acr.org/ac Given patient’s high pre-test probability for an appendicitis and avoidance of radiation exposure, the ER doc ordered ultrasound of right lower quadrant.

6. Normal sonographic appearance of the appendix. Ultrasound, long Six sonographic signs of appendicitis -Diameter >6mm -Lack of compressibility -Inflamed, echogenic peri-appendiceal fat -Hyperemia -Appendicolith -Adjacent fluid collections Six sonographic signs of appendicitis -Diameter >6mm -Lack of compressibility -Inflamed, echogenic peri-appendiceal fat -Hyperemia -Appendicolith -Adjacent fluid collections

7. Our patient, abnormal sonographic appearance of the appendix. Ultrasound, trans Two signs of appendicitis present. Diameter > 6mm Lack of compressibility Two signs of appendicitis present. Diameter > 6mm Lack of compressibility Since there were only two of the six sonographic signs of appendicitis were seen and general surgery had an equivocal exam, the ER obtained a CT of the abdomen. 4871109

8. Normal appendix. Axial, non-contrast CT CT criteria for acute appendicitis -Periappendiceal inflammatory changes -Diameter >6mm -Appendiceal wall thickness >3mm -Intraluminal depth of fluid >2.6mm CT criteria for acute appendicitis -Periappendiceal inflammatory changes -Diameter >6mm -Appendiceal wall thickness >3mm -Intraluminal depth of fluid >2.6mm

9. Our patient, abnormal appendix. Axial, non-contrast CT 4871355 CT criteria met for acute appendicitis -Periappendiceal inflammatory changes -Diameter >6mm -Appendicolith (*) CT criteria met for acute appendicitis -Periappendiceal inflammatory changes -Diameter >6mm -Appendicolith (*)

10. Our patient, abnormal appendix. No kidney stones, fx or infection. Axial, non-contrast CT 4871355

11. Our patient, abnormal appendix. No kidney stones, fx or infection. Axial, non-contrast CT 4871355

12. Our patient, abnormal appendix. No kidney stones, fx or infection. Axial, non-contrast CT 4871355

13. Our patient, abnormal appendix. No kidney stones, fx or infection. Axial, non-contrast CT 4871355

14. Our patient, abnormal appendix. No kidney stones, fx or infection. Axial, non-contrast CT 4871355 * *

15. Our patient, abnormal appendix. No kidney stones, fx or infection. Coronal, non-contrast CT

17. Limited treatment options/alternatives. The patient underwent laporoscopic appendectomy on night of presentation. Outcome 17 Thanks your attention.